Swiss Flight 188, the Normalization of Deviance and a Better Way to Communicate: Lessons for Healthcare Leaders

I recently came across some captivating footage of a Swiss Airlines flight crew dealing with the unexpected loss of an engine. Watch this- you won’t be able to take your eyes off this smooth, competent crew.

As you watch, note:

The highly disciplined communication between the pilots.

How the Captain called early for reinforcements (the second co-pilot) when an anomaly was detected and before he could determine how serious the problem was

The co-pilot’s willingness to challenge the Captain when she felt that he had made an error reading the flight manual, and how the Captain responded

How the crew clearly stated their “intentions” – in effect sharing and agreeing to a clear goal in advance.

A total lack of willingness to “cut corners” for the sake of avoiding inconvenience. The crew adhered 100% to the recommendations in Airbus’s flight manual

Aviation experts call this clip a great example of CRM- crew resource management. CRM is a way of training flight crews to communicate, make decisions and lead others in high-risk situations. It’s now the global training standard in aviation.

The crash of a United Airlines flight in 1978 is credited as the Genesis of CRM: In that accident the crew became preoccupied with defective landing gear and failed to notice that they were running out of fuel. Although the pilot was one of United’s most senior pilots, a lack of clear communication and situational awareness led to the crash. The National Transportation Safety Board concluded:

The Safety Board believes that this accident exemplifies a recurring problem—a breakdown in cockpit management and teamwork during a situation involving malfunctions of aircraft systems in flight… Therefore, the Safety Board can only conclude that the flightcrew failed to relate the fuel remaining and the rate of fuel flow to the time and distance from the airport, because their attention was directed almost entirely toward diagnosing the landing gear problem.

CRM has been in aviation circles for nearly 20 years but has only recently been brought to the clinical medicine– and primarily in the surgical suite. A couple of consulting companies offer CRM programs to hospitals. (Unfortunately my experience has been that even after rigorous implementation of these programs, no OR looks quite like the flight deck of Swiss Airlines. Vanderbilt has been a leader in the area of CRM in healthcare. In 2004 they wrote about their early ambitious work implementing an training program for high-risk areas of the hospital. Four years later researchers from the same university conducted a survey of 30 OR cases and found that the teams were compliant with 60% of the recommended CRM practices.)

Notwithstanding what I suspect are cultural barriers (e.g. physician engagement) to CRM implementation in the clinical setting, I find the principles of CRM really compelling, and suspect that they have particular applicability to healthcare administration. Why?

In my experience, the major advantage of CRM programs is that they 1) (theoretically) empower teams to speak up to “the boss” and ensure all voices are considered in a decision and 2) they ensure that groups are held responsible for making sure that protocols are followed (or are revised). They are, in other words, cultural playbooks.

Many healthcare organizations, in my limited experience, tend to be loosely linked islands of work-around labeled as a “system of care”. The care gets delivered, but generally in a non-standardized way. Hospital executives have only the illusion of control over what happens on the wards and units. There isn’t clear communication of the strategy or goal. And, in the absence of clear and well-considered leadership, teams create work-around solutions.

Diane Vaughan is an American sociologist who popularized the theory of “normalization of deviance” in organizations.

“Social normalization of deviance means that people within the organization become so much accustomed to a deviant behavior that they don’t consider it as deviant, despite the fact that they far exceed their own rules for the elementary safety”. People grow more accustomed to the deviant behavior the more it occurs . To people outside of the organization, the activities seem deviant; however, people within the organization do not recognize the deviance because it is seen as a normal occurrence. In hindsight, people within the organization realize that their seemingly normal behavior was deviant.

This kind of deviant behavior is all over in medical practice. John Banja has written a piece (that I love) on the normalization of deviance in healthcare and notes that the factors accounting for the normalization of deviance are:

1. The rules are stupid and inefficient. (Deviators often interpret rule compliance as irrational and a drag on productivity. The deviator typically understands the problematic rule to have been handed down by authorities who appear wildly out of touch with “life in the trenches,”)

2. Knowledge is imperfect and uneven. (System operators might not know that a particular rule or standard exists; or, they might have been taught a system deviation without realizing that it was so.)

3. The work itself, along with new technology, can disrupt work behaviors and rule compliance (Complex work environments are often dynamic. New technologies and personnel can disrupt ingrained practice patterns, impose new learning demands, or force system operators to devise novel responses or accommodations to new work challenges)

4. Healthcare worker are breaking the rules “for the good of the patient”.

5. The rules don’t apply to me/You can trust me. (When system operators believe they are not tempted to engage in the behavior that the rule or standard is supposed to deter. Thus, the rule is understood as superfluous).

6. Workers are afraid to speak up.

7. Leadership withholds or dilutes findings on system problems. (Findings of system flaws and weaknesses are frequently revised and diluted as that information ascends the chain of command).

How do we as healthcare leaders ensure that we develop the kinds of organizations that aren’t inherently bureaucratic and work-around heavy— while also having in place thoughtful and accepted processes where they matter? How do we develop the kinds of organizations that communicate the depth and severity of problems to management in a timely and open way?

I increasingly think that having an organizational healthcare leadership playbook, based loosely on the principles of CRM, is a great place to begin. It would frame a culture of communication and collaboration.

How would your healthcare organization functionif your principles, priorities and intentions were communicated as crisply as on the fight deck of Swiss Airlines flight 188?

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“Managing capitation can be deceiving. Like flying an airliner, the gauges, levers and controls can make it seem like high-stakes science. It is, partly. But as with all things healthcare this is ultimately about humans, their needs and their behaviors. You eventually learn that managing the payment model is as much an art as is the actual practice of medicine”.